COVID‐19 and cardiac surgery: A perspective from United Kingdom

Abstract The emergence of severe acute respiratory syndrome coronavirus 2 in December 2019, presumed from the city of Wuhan, Hubei province in China, and the subsequent declaration of the disease as a pandemic by the World Health Organization as coronavirus disease 2019 (COVID‐19) in March 2020, had a significant impact on health care systems globally. Each country responded to this disease in different ways, however this was done broadly by fortifying and prioritizing health care provision as well as introducing social lockdown aiming to contain the infection and minimizing the risk of transmission. In the United Kingdom, a lockdown was introduced by the government on March 23, 2020 and all health care services were focussed to challenge the impact of COVID‐19. To do so, the United Kingdom National Health Service had to undergo widespread service reconfigurations and the so‐called “Nightingale Hospitals” were created de novo to bolster bed provision, and industries were asked to direct efforts to the production of ventilators. A government‐led public health campaign was publicized under the slogan of: “Stay home, Protect the NHS (National Health Service), Save lives.” The approach had a significant impact on the delivery of all surgical services but particularly cardiac surgery with its inherent critical care bed capacity. This paper describes the impact on provision for elective and emergency cardiac surgery in the United Kingdom, with a focus on aortovascular disease. We describe our aortovascular activity and outcomes during the period of UK lockdown and present a patient survey of attitudes to aortic surgery during COVID‐19 pandemic.


| BACKGROUND TO COVID-19 AND EFFECTS ON SERVICES FOR CARDIAC SURGERY IN THE UNITED KINGDOM
The severe acute respiratory syndrome coronavirus 2 first emerged in the city of Wuhan, China, in December 2019 and it has since spread rapidly across the globe, causing a disease named as coronavirus disease 2019  in February 2020 and with the World Health Organization declaring a pandemic in March 2020. 1 As of August 20 th , 2020, there were more than 22.2 million confirmed cases of COVID-19 and over 795,000 deaths reported globally ( Figure 1) with the United Kingdom being 12th among countries in term of confirmed cases (more than 326,000) and 5th in COVID-19related deaths (more than 41,000; Figure 2). 2 Public Health England (PHE) published the very first report on COVID-19 on January 22, 2020. Just 1 day later, the Emergency Department at Royal London Hospital swabbed its first potential COVID-19 patient. 3 The declaration of this disease as a pandemic put health care systems in the United Kingdom on alert and the government introduced a national lockdown on March 23, 2020 in an attempt to contain the disease and minimize the transmission risk to others. A campaign was launched under the slogan of "Stay home, Protect the NHS (National Health Service) and Save lives." Although a critical step to combat this highly contagious disease, it created a significant burden on an otherwise freely accessible health care system, the NHS. The NHS had to undergo a significant transformation diverting resources to frontline health care services including ambulance services, emergency departments, and allocation of intensive care beds in preparation for the potential influx of COVID-19 patients and the requirement for ventilatory support (Figure 3). De novo facilities, the Nightingale Hospitals, were created throughout the nation to increase capacity; private hospital capacity was purchased, industries were tasked with producing ventilators and academia with producing treatments and vaccines. Effectively, all elective care was stopped with services only maintained for emergencies.
Amongst the many specialties affected by the NHS service reconfiguration was cardiac surgery, given its ownership of a large resource of ventilated beds normally required in elective practice.
Attempts were made in a number of regions to create centralized cardiac surgical services to continue the provision of care to this high-risk cohort and avoid secondary deaths due to untreated cardiovascular diseases. 4 The Royal College of Surgeons (RCS), Society of Cardiothoracic Surgery in UK and Ireland (SCTS), and the NHS issued guidelines and regular updates on the practice of cardiac surgery during this pandemic, introducing protocols and pathways to minimize the risk of COVID-19 to patients and staff without affecting the quality of service and care to those needing cardiac surgery. [5][6][7][8][9][10][11] The network of centers that perform cardiac surgery in England generally responded to the crisis according to government guidance by reducing or, more frequently, halting elective operating, but with a degree of independence. The exact timeline during which each center wound down elective and urgent services varied according to local circumstances and pressures. The processes by which each center managed patient pathways were dependent on local arrangements. In addition, England, Wales, Scotland, and Northern Ireland, each with its own devolved government, responded differently. This paper focusses on the experience of Liverpool Heart and Chest Hospital (LHCH) with changes to service provision for cardiac surgery, focussing on aortovascular patients.

| RECOMMENDATIONS AND GUIDELINES DURING COVID-19 IN BRITAIN
On March 20, 2020, the RCS published its initial, brief guidance for surgeons who were working during the COVID-19 pandemic, emphasizing the safety of the working force as well as the maintenance of emergency surgical workforce and capabilities. 5 The detailed guidance came into force on March 26 th , 2020 outlining the scope of patient selection and flow of surgical practice across the United Kingdom. Since then, the guidelines have been updated four times, lastly on June 5 th , 2020. The initial guidance involved the cancellation of all elective operating cases, with a focus on operating on urgent/emergency and otherwise life-saving procedures. 6 Patients were categorized into four levels according to their need for surgery: • Priority level 1a Emergency-operation needed within 24 h.
• Priority level 1b Urgent-operation needed with 72 h.
• Priority level 2 Surgery that can be deferred for up to 4 weeks.
• Priority level 3 Surgery that can be delayed for up to 3 months.
• Priority level 4 Surgery that can be delayed for more than 3 months.
With the gradual decline in the cases of COVID-19, the service gradually resumed its activities, slowly reintroducing elective surgery on a phased basis. Elective cases were prioritized as Red, Amber, Green (RAG rating) with red been classified as "urgent elective." With a similar approach but at a more specialized level, the SCTS introduced national guidelines on the performance of cardiac surgery. As its initial response, the society introduced a clear cardiothoracic surgery escalation framework on March 16 th and 18 th , 2020; which outlined the routine practice of operating theaters, clinics, and the running of a multidisciplinary team (MDT) meetings. 7 It classified cardiothoracic patients in four areas, the obligatory in-patients, which required surgical intervention, the alternative (nonsurgical) pathways including inpatients and those to be managed by ambulatory base services, the day-cases, and finally, the outpatients, whose hospital visits were to be kept at the minimum safe level. The society also developed a clear pathway for patient selection during the initial lockdown and to smooth the gradual resumption of elective activity. The guidelines not only included patient selection but also focused on triage methods of such cohort, COVID-19 screening methods and tests, the use of personal protection equipment, and the management of operating theaters. These guidelines were implemented nationwide and helped in containing the spread of COVID-19 in cardiac surgery patients. 8 The society's latest guideline on resumption of elective activity eliminates the requirement for preoperative radiological screening if they have been self-isolating for 14 days before surgery, provided that they have no COVID-19-related symptoms and have negative COVID-19 nasopharyngeal swab within 72 h of surgery date. 9 The NHS also issued several, nationwide guidelines to provide insights on speciality practice during the COVID-19 pandemic. Most of the clinical guidelines and recommendations were interlinked with the work of the RCS and SCTS. The NHS and PHE recognized that cardiothoracic surgery, like any other speciality, needed service modification which depended on the unit and the region of service, considering that some cardiothoracic units are incorporated as part of large trauma centers while others are tertiary units without emergency department service. 10 The NHS categorized the patients into six major groups:  In addition to the above, the work of the cardiothoracic team was expanded to have a consultant-led service, including patient assessment, daily reviews, and decision-making processes. The NHS also advised to restructure training and education needs during this time period to give priority to COVID-19 patient care provision. 12,13 In its latest guide, the NHS advised to utilize a remote consultation, where appropriate. However, when face-to-face consultations were needed, patients were brought in for further assessment in a controlled and organized manner. 11 PHE, NHS, SCTS, and RCS eventually merged their statements to restructure the daily practice of cardiac surgery including modification of hospital setups, patient selection, and screening process as well as standards for intubation, operating, and provision of perioperative care for such patients. The joint statements were released in accordance with the severity of the COVID-19 pandemic within the UK general population and the phase of the disease.

| SERVICE TRANSFORMATION
The NHS has been stretched to provide care for the already aging population alongside the new cases of infected COVID-19. As such and due to limited capacity, there have been some attempts at the reconfiguration of services, in some regions, by creating centralized units to provide care for subspecialities that are not in direct response to COVID-19. This service. 14 It is important to emphasize that the base of developing such centralized services and the detailed protocol was to provide a COVID-19 free environment for patients undergoing cardiac surgeries. This is a very critical point as COVID-19 seems to have a significant correlation with cardiovascular diseases and outcomes. [15][16][17] Maintenance of a COVID-19 free environment with clean patient pathways was key to maintaining a limited but safe service.
There was a significant reduction in the operational activities, as high as 83% in some cardiac surgical units. 4 Our center observed similar reductions ( Figure 4). Eventually, the establishment of standardized patient pathways (Appendix 2) for perioperative care and management in the theater (Appendix 3) aided in a gradual increase in surgical activities. According to regional pathways (NUCS and PLECS), patients were classified into four major categories: • Level 1: Elective patients who have indications for routine cardiac surgery and would normally be added to an elective waiting list. For NUCS the decision-making process started with the receipt of an urgent inpatient referral, after triage at the referring regional cardiac hospital (Blackpool and Manchester). These were directed to our local COVID-19 daily MDT along with our local urgent referrals.
All our 10 weekly MDTs were amalgamated into a single and virtual COVID-19 MDT with widespread attendance. After review of the available information, an outcome was communicated to the referring clinical team and the patient. If the intervention was deemed necessary, then procedural planning took place and the case was allocated to a consultant and the date for surgery identified. Emergency referrals were processed in the usual way by on-call staff.
A number of patients requiring emergency care were referred to Liverpool on the basis of the NUCS arrangement.  19 The evidence base underlying this advice was opaque at best. We "RAG rated" (Red, Amber, Green) and chose to operate on the so-called "Red urgent elective" patients with COVID screening and "clean hospital pathways." The definition of red was a symptomatic severe disease. During this period, we made no adjustments to size-based guidelines.

| Referral activity
A commonly observed phenomenon during this period was a dramatic reduction in both elective and urgent/emergency referrals thought to be due to very few patients presenting to the hospital due to a fear of COVID-19 and local triage by referring doctors.

| Outcomes of operated aortovascular patients
We examined our outcomes between the dates of March 1, 2020 and July 4, 2020. A total of 59 patients were operated (Table 1) during this period. In normal times we would expect the four aortovascular surgeons to perform roughly one elective/urgent case each per week over 42 weeks/year (i.e., total 56 cases) plus emergencies, suggesting our aortovascular activity was largely maintained during this 14-week period. (iv) Medically managed patients: We managed 15 aortovascular patients without surgery either because it was not indicated or because patients were unfit for the necessary surgical procedure. Eight were type A dissections (moribund, 3; major stroke, 1; subacute, 1; or patient too frail/comorbid; 3). Five patients had surgically relevant thoracoabdominal aortic dissection or aneurysm but were too frail/comorbid; one was an uncomplicated acute type B (COVID-19 positive). One patient had a root abscess that was COVID-positive and died while awaiting a negative swab before transfer.
No patient in this cohort died of postoperative COVID-19 pneumonia. It should be noted that our critical care area is divided into four distinct rooms, an arrangement that facilitated the isolation of COVID-19-positive patients. During this period, we regularly admitted ventilated patients from neighboring acute hospitals with communityacquired COVID-19. In summary, we attempted to maintain our aortovascular patients COVID-19-free via a combination of preoperative screening, strict theater procedures, and separate pathways the "clean" and the COVID-19 cohort (Appendces 1-3).
It should be noted that our preoperative screening protocols changed as evidence presented itself. At the start of the lockdown period, we performed routine CT scanning and bronchoalveolar lavage (BAL) in theater or when a patient returned to intensive treatment unit.
During late June 2020, we eventually abandoned CT scanning and a plain chest radiograph was used instead to identify individuals with early or suspected COVID pneumonia. In addition, it became clear the BAL was highly sensitive in the detection of viral RNA, but it was unclear whether this was simply dead virus indicating previous exposure or rather an active infection. Our experience showed that a positive BAL was of no consequence for the clinical course of the patient but created major issues for bed capacity with a need for isolation.
For this reason and during late July, BAL was stopped in elective patients with a preoperatively negative COVID-19 swab, normal chest X-ray, and blood tests who had been isolating for 2 weeks.
We are thus only aware of one patient who should have undergone urgent surgery for a root abscess but died following delays while awaiting his status to change from COVID-19 positive to negative. To our knowledge, no patients came to harm while on our waiting lists for delayed elective surgery. We see this as validation of the systems we developed to balance the need to make our critical care beds available for the national COVID-19 pandemic and the needs of our patients with life-threatening cardiovascular disease.
After this period, we gradually returned to normal work patterns, with surgeons planning their operating lists independently, progressively increasing elective activity as hospital pathways allowed. We still use a RAG rating system at present.

| PATIENT PERSPECTIVE
To better understand the beliefs and attitudes of patients with aortic pathology during COVID-19, we conducted a survey through Aortic Dissection Awareness UK and Ireland (ADA UKI).
A structured questionnaire was developed and preoperative patients who are members of ADA UKI were invited to complete it from August 17 and 25, 2020. A total of 29 responses were received and the results are presented in Table 2.
Among the 29 patients, only one of them considered himself as "awaiting surgery" while the rest 28 patients considered themselves  others diverted their activity into a more centralized, regional hub to be able to deliver emergency, specialist services. NHS England has been in the frontline combating COVID- 19